What is Urinary Incontinence?

Bladder control problems are very common, especially among older adults. Urinary incontinence refers to the accidental release of urine during normal activities of daily living. The two main types of urinary incontinence are:

What causes Urinary Incontinence?

Stress incontinence is caused by stretched pelvic floor muscles, such as from childbirth or weight gain. The bladder drops downward and pushes against the vagina, preventing tightening of the muscles that ordinarily close off the urethra. This can cause leakage when extra pressure is exerted with coughing, sneezing, laughing, or other activities. This may get worse with the drop in estrogen that comes after menopause.

Urge incontinence occurs when the bladder muscle contracts involuntarily and can be the result of age-related changes in the bladder muscle, Parkinson’s disease, stroke, kidney or bladder stones and tumors putting pressure on the bladder.

It is common for a woman to have mixed incontinence, usually a combination of stress incontinence and urge incontinence.

What treatments are available for Urinary Incontinence?

Incontinence can be cured or at least managed with a variety of treatment options.

With stress incontinence, many women can get good results from using pelvic floor (Kegel) exercises; these exercises strengthen the pelvic muscles involved in urination. Other techniques, such timed urination training and lifestyle changes such as losing weight and identifying foods which irritate the bladder, can offer help as well. Medical devices such as pessaries, which are rubber or plastic devices that are placed into the vagina, can help support the pelvic structures. For difficult conditions that fail to respond to more conservative measures, surgery may be required. In many instances, these procedures can be performed on a minimally invasive basis, allowing for a quicker recovery time and return to normal activities.

With urge incontinence, learning to retrain the bladder is often helpful. Medications may also help, although they may have bothersome side effects. If medications, physical therapy and biofeedback fail to relieve the symptoms, Sacral Neuromodulation (interstim) or Botox injections inside the bladder may prove helpful.

What is Pelvic Organ Prolapse?

Pelvic organ prolapse is a condition in which the muscles and ligaments supporting the organs of the pelvis weaken or break down. Over time, organs such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall, out of their normal positions. The condition may have an adverse affect on sexual intercourse and such bodily functions as urination and defecation. Women with the condition may feel pelvic pressure and discomfort. Some women who develop vaginal prolapse, however, do not experience any symptoms. It is estimated that 30-40% of women will develop some degree of vaginal prolapse in their lifetime, and it usually occurs in women older than 40. The condition does not get better on its own. Without treatment, the prolapsed organs may eventually fall farther into the vagina or even through the vaginal opening.

What causes Pelvic Organ Prolapse?

Pregnancy and childbirth, particularly multiple births, can weaken the support structures with the pelvis. Menopause, and its associated drop in estrogen levels, can also lead to the condition, since estrogen is a hormone that helps keep the muscles and tissues of the pelvic area strong. Some types of hysterectomy may make a women more at-risk for developing pelvic organ prolapse.Without the uterus, the top of the vagina may gradually prolapse toward the vaginal opening. Other contributing conditions may include strenuous physical activity, conditions or abnormalities of the nerves or connective tissues, or previous pelvic surgeries. Women with advanced vaginal prolapse may also suffer from urinary incontinence.

What treatments are available for Pelvic Organ Prolapse?

Treatment depends on the degree of prolapse and factors such as the woman’s age and lifestyle. Nonsurgical treatment may be indicated for women who cannot undergo surgery for medical reasons, have few or no symptoms associated with the condition, and are not sexually active.

At Loma Linda University Medical Center, our comprehensive treatment options for pelvic floor problems include a variety of medications and a range of non-surgical treatments such as:

Surgery is the treatment option that most sexually active women elect because the procedure is usually effective. At Loma Linda University Medical Center, our surgical treatments include laparoscopic procedures that are performed on a minimally invasive basis. The advantages are a shorter recovery period, less pain and scarring, and a quicker return to normal activities. They include:

Pelvic pain falls into two general categories: acute pelvic pain is new, short-term pain that may be caused by pelvic inflammatory disease or an event such as ovarian cyst rupture or torsion, etc. Chronic pelvic pain has been ongoing for a while and may have been treated without success. Conditions that may fall into this category include endometriosis, pelvic floor spasm and interstitial cystitis.

What treatments are available for pelvic pain?

Treatment for pelvic pain depends on the cause, the intensity and frequency of the pain. Sometimes pelvic pain is treated with medications, including antibiotics if necessary. Treatment may involve surgery or other procedures if the pain indicates a problem with one of the pelvic organs. A physician is the best source for information about various treatments for pelvic pain.

What causes abnormal bleeding?

There are many possible causes for abnormal vaginal bleeding. By itself, it does not necessarily indicate a serious condition. Some causes include a problem with a pregnancy or possible pregnancy and needs to be evaluated by a physician:

• Heavy vaginal bleeding or bleeding that occurs before 12 weeks may indicate a serious problem such as an Ectopic pregnancy or miscarriage.• Heavy vaginal bleeding or bleeding that occurs after 12 weeks also may indicate a serious problem, such as placenta previa.

Other cause of abnormal bleeding may include ovulation, a hormonal imbalance, birth control pills, an intrauterine device (IUD, infection of the pelvic organs (vagina, cervix, uterus, fallopian tubes, or ovaries), sexually transmitted diseases (STDs) and pelvic inflammatory disease (PID), which causes inflammation or infection of the uterus, fallopian tubes, or ovaries.

What treatments are available for abnormal bleeding?

There is no home treatment for abnormal vaginal bleeding. With some types of vaginal bleeding, it may be okay to wait to see if the bleeding stops on its own. Any concerns about abnormal bleeding should be addressed with a physician. And for any bleeding that continues or gets worse, a visit to a doctor is needed to determine the reason for the bleeding.

Women who use tampons for abnormal vaginal bleeding must be sure to change them often and not leave one in place when the bleeding has stopped. A tampon left in the vagina may increase the risk for toxic shock syndrome, a rare but life-threatening illness that develops suddenly after a bacterial infection rapidly affects several different organ systems.

What is interstitial cystitis?

Also called painful bladder syndrome, interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and pelvic region. The symptoms may include mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area. It is often accompanied by an urgent or frequent need to urinate. There may be intense discomfort when the bladder fills and some relief with emptying, or throbbing pelvic pain after sexual intercourse. A woman may also have had multiple diagnoses and treatments for urinary tract infection when in fact all test (urine cultures) have been normal.Women sufferers may find their symptoms often get worse during menstruation. Of the estimated 1.3 million Americans with IC, more than 1 million are women.

What causes interstitial cystitis?

The causes of IC are not clearly understood. One common theory is that there is absence or break in a protective surface layer – the GAG layer- of the bladder. Currently, this theory is the basis of many of our most effective treatments. Many women with IC may also suffer from other conditions such as irritable bowel syndrome and fibromyalgia. Some research indicates that IC may be part of a more general condition that causes inflammation in various organs in the body. There may also be a genetic connection that scientists are now exploring, as well.

What treatments are available for interstitial cystitis?

There is no cure for IC, so treatment is aimed at relieving the symptoms that accompany the condition. An oral medication cocktail can relieve symptoms in many women. Others find relief through bladder instillation of a liquid medication such as Heparin, which coats the bladder wall and provides a protective layer. Hydrodistension of the bladder not only helps in diagnosis, it is often therapeutic.

Sacral neuromodulation, also called Interstim, has shown to be an effective treatment for IC, although the reasons are not fully understood. Current theories suggest that Interstim, which sends electrical impulses to the nerves, may interrupt abnormal pain signals that travel between the bladder and the brain.

A multidisciplinary approach may be necessary, during which a urogynecologist and a specialist in pelvic floor and bladder issues works with a gastroenterologist on dealing with irritable bowel issues, or an internist or rheumatologist on autoimmune issues. A pelvic floor physical therapist can help via exercise, giving myofascial massage and providing transcutaneous electrical nerve stimulation (TENS) therapy. A psychologist or therapist can assist with stress reduction and meditation, and complimentary medicine such as acupuncture can help relieve pain. Surgery is an option if more conservative treatments have failed and the pain is disabling. Many approaches and techniques are used, and your doctor can discuss which options may be best for you.

What is fecal incontinence?

Fecal incontinence is the inability to control your bowels. When you feel the urge to have a bowel movement, you may not be able to hold it until you reach a toilet. Or stool may leak from the rectum unexpectedly, sometimes while passing gas. More than 5.5 million Americans have fecal incontinence. It affects people of all ages—children and adults. Fecal incontinence is more common in women and older adults, but it is not a normal part of aging.

What causes fecal incontinence?

There can be many causes of fecal incontinence. Conditions that alter bowel habits, such as diarrhea or constipation, are one common cause. Damage to the ring-like muscles at the end of the rectum, called sphincters, can also result in fecal incontinence. The sphincters keep stool inside. When damaged, the muscles aren’t strong enough to do their job and stool can leak out. In women, damage to anal sphincters (either to the nerve which activates the sphincter muscle, or an actual break or disruption in the muscle itself, or a combination of these) during childbirth is the most common reason for fecal incontinence. Hemorrhoid surgery can also damage the sphincters. Pelvic floor disorders, such as when the rectum drops down into the anus (rectal prolapse) or when the rectum protrudes into the vagina (rectocele) can also cause fecal incontinence.

What treatments are available for fecal incontinence?

Treatment will depend on the cause of your incontinence, so getting a proper diagnosis is key. Since the vast majority of women with FI have it because of damage from childbirth, anorectal testing allow us to determine strength of the external anal sphincter (EAS) and internal anal sphincter (IAS). If anorectal testing determines a weakness in the normal resting pressure in the sphincter, it is likely that the IAS is weak or disrupted. If testing determines weakness in squeeze pressure in sphincter, then the EAS is weak or disrupted. Based on these tests, an MRI of the anal sphincter may be required to actually visualize where and how much the anal sphincter is damaged. Conservative treatments for FI may include modifying the diet and using medication to thicken stools and slow down its passage, as well as physical therapy. Surgical treatment may include an overlapping anal sphincteroplasty.

What is urinary retention?

Urinary retention is the inability to empty the bladder of urine. In some cases, you may be able to urinate but have trouble starting the stream or emptying your bladder completely. You may also feel an urgent need to urinate but be unable to when you actually get to the toilet. Or, you may feel you still have to go after you’ve finished urinating. Although chronic urinary retention is not life threatening, it can lead to damage of the kidneys.Those suffering with chronic urinary retention should consult a qualified health professional.

What causes urinary retention?

There can be many causes of urinary retention, the two common reasons in women are advanced pelvic organ prolapse and abnormal communication between the brain and spinal cord with the bladder and urethra. An obstruction in the urinary tract may disrupt the free flow of urine. Nerve problems can interfere with signals between the brain and the bladder. If the nerves aren’t working properly, the brain may not get the message that the bladder is full. Even if you know that your bladder is full, the bladder muscle may not get the signal that it is time to push urine out of the bladder, or the sphincter muscles may not get the signal that it is time to relax. A weak bladder muscle can also cause retention. A urinary tract infection (UTI) may cause retention if the urethra becomes inflamed and swells shut. Pelvic floor prolapse, in which the bladder may droop into the vagina, can also make completely voiding difficult.

What treatments are available for urinary retention?

Treatment of urinary retention depends on the root cause. In some cases, discontinuation of certain medications may improve urinary function. Intermittent self catheterization may also help. If there is a clear cause for the urinary retention such as pelvic organ prolapse, then surgery to fix the prolapse will treat the retention. However, in cases where there is abnormal communication between nervous system and bladder/urethra, Sacral Neuromodulation may be the best approach. Your doctor will conduct a full diagnostic work-up before recommending the best course of treatment for you.

What is recurrent urinary tract infection?

A urinary tract infection (UTI) is exactly that: an infection that can happen anywhere along the urinary tract, which includes the bladder, kidneys, ureters (the tubes that take urine from each kidney to the bladder) and urethra (the tube that empties urine from the bladder). Recurrent urinary tract infection consists of at least two infections of the bladder in six months, or three infections in one year.

What causes recurrent urinary tract infection?

Also called cystitis, this common condition occurs when vaginal atrophy (especially with menopause) leads to a change in vaginal flora and an increased rate of UTI. Pelvic organ prolapse can cause a stagnation of urine and predispose a woman to a UTI. A foreign body in the urinary tract (kidney stone, suture in bladder from a previous operation, cancer, abnormal anatomy etc.) can also cause recurrent UTI. If, after a thorough evaluation, there is no identifiable cause, low dose antibiotics may be prescribed.

What treatments are available for recurrent urinary tract infection?

A recurrent UTI should be treated more aggressively than a single UTI because of the risk of kidney infection. Antibiotics may used for a longer period of time (as long as 6 months to 2 years), or stronger antibiotics may be needed than what is used for a single, uncomplicated instance of cystitis. Medications may help reduce the burning and urgency associated with cystitis. If an anatomical abnormality is present, surgery to correct the problem may be recommended.

Other urogynecology services provided include:

Treatment of Urogenital Fistula

Fistula refers to abnormal communication between two areas in the body. Some of the common types of fistulas occur between the bladder to vagina, the rectum to vagina, the urethra to vagina and the bladder to uterus. Fistulas may result from an injury to the genitourinary tract. Symptoms may include incontinence, pain, abdominal distension, or fever, depending on the type of fistula. For these women, reconstructive pelvic surgery can address the complications that may be causing this condition.

Post-surgical Sexual Dysfunction

Some women may experience severe pain during sexual intercourse after a prior surgery. For these women, reconstructive pelvic surgery can address the complications that may be causing the discomfort.

Counseling On Elective Cesarean Section

Women who have—or have had--pelvic floor dysfunction may benefit from a SELECTIVE c-section to avoid the trauma of vaginal birth. A pregnant woman with a history of fecal incontinence or surgery for it, history of stress incontinence or surgery for it, history of urogenital fistulas or surgery for pelvic organ prolapse may want to consider having a c-section to protect her pelvic floor.